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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707097
Report Date: 01/31/2022
Date Signed: 02/02/2022 02:17:00 PM

Document Has Been Signed on 02/02/2022 02:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PARK AVENUE ADULT RESIDENTIAL FACILITIESFACILITY NUMBER:
430707097
ADMINISTRATOR:EUSTAQUIO,CECILIAFACILITY TYPE:
735
ADDRESS:1992 & 1998 PARK AVENUETELEPHONE:
(408) 241-0605
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY: 12CENSUS: DATE:
01/31/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
03:32 PM
MET WITH:Cecelia EustaquioTIME COMPLETED:
05:29 PM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA) arrived at the facility to conduct an unannounced annual inspection. Upon arrival at the facility, LPA knocked on the door and rang the door bell. LPA was unable to hear whether or not the doorbell made any noise. After nobody answered the door, LPA opened the door and called out for staff in the facility. LPA was greeted by Administrator Cecelia Eustaquio (Admin). Admin was not initially wearing a mask, but put on a cloth mask upon conversing with LPA.

LPA told Admin that he was at the facility to conduct the annual inspection. Admin stated that she was currently positive with COVID and asked LPA to come back later. Admin stated that they had been diagnosed with COVID 7 days ago but that she was now all clear. LPA asked Admin if she had reported her COVID positivity to licensing, Admin stated that she had not gotten around to it. While LPA and Admin were conversing, an unidentified resident (R1) came into the entryway. R1 was not observed to be wearing a mask. Upon request of Admin, LPA called Assistant Administrator Merv Reyes (AA) to discuss the matter further. AA indicated that Admin did not live at the facility, but did go

In further conversation with AA, AA indicated that a resident of the facility had been COVID positive in early January after having been abroad for the holidays. Resident contracted COVID while en route back to the facility, but did not return to the facility until their COVID positivity was cleared.

Due to COVID exposure at the facility, LPA did not conduct that annual inspection

Deficiencies cited, see 809-D. This report was reviewed with Assistant Administrator Merv Reyes and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 02/02/2022 02:17 PM - It Cannot Be Edited


Created By: Ryker Heberle On 01/31/2022 at 05:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARK AVENUE ADULT RESIDENTIAL FACILITIES
FACILITY NUMBER: 430707097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/01/2022
Section Cited
CCR
80072(a)(2)

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80072 - Personal Rights - (a) ...each client shall have personal rights which include, but are not limited to... (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by:
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Facility is to have COVID positive staff leave the facility immediately and isolate until cleared of COVID, conduct response testing for COVID19, and review/revise facility mitigation plan to outline facility plan for COVID19 response.
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Based on LPA observation, the licensee did not comply with the section cited above by allowing COVID positive staff to continue working at the facility while residents and COVID positive staff were not wearing masks, which posed an immediate health, safety or personal rights risk to persons in care.
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Type B
02/07/2022
Section Cited
CCR80061(b)(1)(H)

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80061 - Reporting Requirements - Upon the occurrence... of the events specified... a report shall be made to the licensing agency within the agency's next working day during its normal business hours... (H) Epidemic outbreaks. This requirement was not met as evidenced by:
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Administrator to review reporting guidelines in Title 22 and provide proof of correction by POC due date
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Based on observation, the licensee did not comply with the section cited above by not reporting COVID positive resident and staff member to licensing, which posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Ryker Heberle
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2